Plasma Exchange to Rescue Children with Rodenticidal Hepatotoxicity Who Met Listing Criteria for Urgent Liver Transplantation

Abstract

Background: We describe our experience with low-volume plasma exchange (PLEX-LV) to treat rodenticidal hepatotoxicity in children. Methods: From prospectively collected database of 82 rodenticidal hepatotoxicity patients admitted in our department from December 2017 to January 2021, we retrospectively analyzed outcomes in children (≤18 years). Patients were characterized as acute liver injury (ALI, coagulopathy alone) or acute liver failure (ALF, encephalopathy). King’s college criteria and Kochi criteria (MELD score ≥36 or baseline INR≥ 6 with hepatic encephalopathy) (Saraf et al. PMID: 26310868) were used to assess need for urgent liver transplantation. In-hospital outcome was recorded. Results: Twenty-eight children (females: 61%; age: 16±2 years, mean±SD) with rodenticidal hepatotoxicity presented 4 (2-5; median, range) days after consumption (suicidal intent:27, accidental:1). Eighteen patients (64%) had ALI (MELD: 19.8±8.5) and 10 (36%) had ALF (MELD: 35.1±5.6). Nine patients (ALI: 2, ALF: 7) fulfilled King’s college criteria, six of whom (ALF: 6) also fulfilled Kochi criteria for urgent liver transplantation. Three patients were mechanically ventilated. All patient families opted against liver transplantation. All children received standard management, including N-acetyl cysteine; ALF patients also received anti-cerebral edema measures. In addition, 14 patients (ALI: 4, ALF: 10) were treated with PLEX-LV (3.7±0.9 sessions, volume: 28±7 ml/Kg body weight) and peri-procedure low dose prednisolone. Hospital stay was 11.3±5 days for those who underwent PLEX and 8.0±2.7 days for other patients. Twenty-six patients were discharged in stable state, while 2 died in- hospital (presented 5 and 8 days after rodenticide consumption). Of 9 patients who met King’s college criteria for liver transplantation (15.4±2.9 years old, females: 78%, MELD: 37.5±2.2), 7 (78%) survived with PLEX-LV. Of 6 patients who met Kochi criteria, 5 (83 %) survived with PLEX-LV. Conclusion: PLEX-LV shows promise as an effective non-liver transplant treatment in children with rodenticidal hepatotoxicity.